Electronic Medical Records

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Electronic Medical Records

• Electronic Medical Records
• Can Help EliminateRacial Disparities in Health
  Outcomes
• Neil Calman, MD
• President and CEO
• Kwame Kitson, MD
• Medical Director
• The Institute for Urban Family Health
• September 2004

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What do we mean by health disparities?
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Defining Health Disparities

• A difference in life expectancy between people of
  color and whites - whites have a life
  expectancy of approximately 7 years longer than
  African-Americans
• A difference in health care access and in the
  treatment given by health care providers
• A difference in the outcomes of diseases all
  else being equal
• A difference in the complication and death rates
  of common diseases

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Documenting Racial Disparities ..LIFE EXPECTANCY
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Diabetes Complications

• Kidney Disease
• The rate of diabetic end stage renal disease is
  2.7 times higher among African Americans than
  among whites.
• Eye Disease
• Rates of blindness due to diabetes are only half
  as high for whites as they are for rest of the
  population.
• Mortality
• Diabetes-related mortality rates for
  African-Americans, Hispanic Americans, and
  American Indians are higher than those for white
  people.

Source CDC/ AHRQ
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Cancer

• Hispanics have a higher incidence and higher
  mortality rates due to cancer of the stomach,
  liver, and cervix than non-Hispanic Whites.
  (Source American Cancer Society)

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Disparities in Diagnostic Care

• The length of time between an abnormal screening
  mammogram and the follow-up diagnostic test to
  determine whether a woman has breast cancer is
  more than twice as long for Asian American,
  black, and Hispanic women as for white women.
• (Source CDC/ Agency for Healthcare Research
  and Quality)

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Discrimination in Care
Source Kaiser Family Foundation
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CDC Grant to End Disparities in Diabetes and
Cardiovascular Disease in the Bronx

• Covers 4 Zip codes in the Bronx with a total
  population of 250,000 people
• Coalition of 40 community-based organizations and
  faith organizations
• Many patients have enormous health and social
  problems that need to be addresses
• Primary and secondary prevention often take a
  back seat to dealing with urgent issues
• The check-up is replaced by dealing with health
  maintenance issues at every visit

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The Institute for Urban Family Health

• Owns 6 Federally-qualified community health
  centers (FQHCs) and operates 6 other centers for
  Continuum Health Systems its partner hospital
  system.
• Operates 9 additional part-time sites which
  provide care to people who are homeless
• Co-sponsors a family medicine residency program
  and operates its model family practice
• Receives 18 different Federal, State and private
  grants to serve people with special health care
  needs

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EPIC

• Installed in 12 full-time centers in Fall 2001
  with EpicCare roll-out in Spring 2002
• Installed in Residency Program July 2004
• Installation planned for part-time homeless
  health care sites for 2005

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The Community Speaks .

• Focus Group Findings On Trust
• For a black man and a white man with the same
  symptoms, they send the Black man home and put
  the white guy in the hospital for observation.

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How We Build Trust

• Roles and responsibilities of health care
  providers in the information age
• Provide information to patients to help them make
  decisions about their own health-related
  behaviors and their own health care choices
• Provide advice, diagnosis and treatment of health
  care problems as well as preventive health
  guidance and procedures
• Provide care in a way that safeguards patients
  from medical and nursing errors
• Maintain a complete database of readily available
  health education information
• Make health education materials readily available
  to them
• Let them own their own medical records

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The Institutes Implementation of EMRs to Reduce
Health DisparitiesFlat Panel Displays

• Flat Panel displays were chosen so they could be
  seen by both the provider and the patient.
• This changes the fundamental sense of secrecy
  that has previously surrounded the medical record
• Tablets were rejected because they were the least
  able to be shared with patients
• Workflows and dialogs have to be re-learned to be
  comfortable using the display as part of the
  patient encounter.

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The Institutes Implementation of EMRs to Reduce
Health DisparitiesPrinters in Every Exam Room

• Epic provides excellent resources for making
  patient education a part of the encounter
• We routinely print a custom designed After Visit
  Summary which has patient friendly headers like
  These are the vital signs that were taken today
  and There are the orders that were made today in
  your care
• Patients are encouraged to review and keep copies
  of all of their AVS notes
• Labs which come back through the interface can be
  printed and a copy given to patients in the exam
  room

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The Institutes Implementation of EMRs to Reduce
Health DisparitiesPrinters in Every Exam Room

• Health education materials available in both
  English and Spanish are printed in the exam room
  and may be annotated as the provider reviews the
  information for the patient
• Weight and Blood Pressure Monitoring can be
  graphed and printed for the patients an
  excellent motivational tool especially if they
  are doing well
• Patients walk out with paper sufficient to
  provide them a complete view of their health
  status and details of all the things that were
  recorded about them.

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The Institutes Implementation of EMRs to Reduce
Health DisparitiesReports

• We are now able to follow-up on issues never
  before possible.
• Consults ordered but no report has been received
• Chronic medications that are not being renewed
  at the right intervals
• Patients who are missing certain health
  maintenance procedures appropriate for their
  gender and age

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The Institutes Implementation of EMRs to Reduce
Health DisparitiesBPAs

• In low income communities of color in New York
  City, patient have many social and economic
  concerns and health care is sometimes relegated
  to a lower priority
• We have eliminated the concept of the check-up
  and used BPAs to remind providers at every visit
  of what health maintenance and early detection
  procedures are needed at the time of every visit
• Reports enable us to outreach to patients who are
  not coming in for a visit but who are missing
  critical health maintenance procedures

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The Institutes Implementation of EMRs to Reduce
Health DisparitiesLetters

• Providers are encouraged to send letters to
  patients with all results that come back from
  diagnostic procedures
• Many templated letters make communication with
  patients easier and provide patients with further
  documentation of what tests they had done and
  what the next step is.
• Receiving communications from doctors helps to
  build a trusting relationship.
• If patients expect results letters than they stop
  calling the office for results and this increases
  efficiency of the practice

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Questions for Thought !

• Ethical questions we must still face in the
  roll-out of electronic medical records
• How do we redefine the roles and responsibilities
  of the providers and the patients ?
• What do we do with all the information we now
  have ?
• What responsibility do we have to reach out to
  patients with information ?
• Where do the resources come from in the outreach
  and follow-up which needs to be done ?
• How do we prioritize our efforts without an
  adequate scientific basis for what we are doing ?

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Using Technology to Improve Quality of Care
Kwame A. Kitson, MD Medical Director The
Institute for Urban Family Health
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IUFH Pre-EpicCare CQI Review

• Resource allocation limited organization- wide QI
  topic review to three topics per year.
• Areas covered included HIV, diabetes, adolescent
  screening for tobacco and substance abuse,
  postpartum care
• Interventions that worked best were those that
  facilitated better documentation by providers
  (example stamps)

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IUFH Pre-EpicCare CQI Review

• Average time spent on chart review-
• 30 minutes to one hour per chart depending on
  the study
• Average time it took to complete studies-
• 3 months.
• Chart reviewers were doctors and nurses at our
  centers. Time spent on chart review made it more
  difficult for them to complete other
  administrative tasks and patient follow-ups

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The Transition OF CQI into EpicCare

• IUFH transitioned all 13 centers into EpicCare
  between October 2002 and January 2003
• Within the first six months provider productivity
  matched pre-EpicCare levels.
• In 2004, unprecedented productivity levels have
  been seen.

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October 2003- Release of Superhero Best Practice
Alerts
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BEST PRACTICE ALERTS
PNEUMOVAX SEASONAL FLUVAX BREAST CANCER
SCREENING CERVICAL CANCER SCREENING LEAD
SCREENING MAMMOGRAPHY SCREENING
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BEST PRACTICE ALERTS

• OPHTHALMOLOGY CONSULTS FOR DIABETICS
• HGBA1C TESTING AND CONTROL
• PEAK FLOW MEASUREMENTS FOR ALL ASTHMATICS
• NEPHROLOGY CONSULTS FOR PATIENTS WITH GREATER
  THAN 1.8 SERUM CREATININE
• LDL SCREENING
• LIVER FUNCTION TESTING FOR PATIENTS ON STATINS
• and many others.

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DID IT WORK ?

• Initial concern about the introduction of best
  practice alerts (BPAs) replaced by enthusiasm
  for the improvement seen in multiple clinical
  areas.
• Keys to Success
• Making sure the BPAs used generally accepted
  standards for testing and treatment indications
• Making sure that the BPAs were accurate in
  capturing services rendered
• (e.g. there are many CPT codes PAP testing)

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An Exponential Increase in CQI Activity

• EPICCARE/CLARITY DATABASE WITH CRYSTAL REPORTING
  HAVE ALLOWED FOR AN EXPNENTIAL INCREASE IN
  REPORTING.
• OVER A DOZEN CLINICAL AREAS ARE BEING REVIEWED
  SIMULTANEOUSLY
• POTENTIAL FOR REVIEW IS LIMITLESS

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PNEUMOVAX PRE AND POST BPA
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HGBA1C CONTROL PRE AND POST BPA
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CERVICAL CANCER SCREENING PER VISIT
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MAMMOGRAMS PER VISITFemales Ages 40-70
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LEAD SCREENING TESTS FOR TWO YEAR OLDS PRE AND
POST BPA
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OPHTHALMOLOGY CONSULTS FOR DIABETICS PRE AND POST
BPA
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Next Steps

• CONTINUE MULTIPLE MEASURE MONITORING
• MONITOR THE USE OF BEST PRACTICE ALERTS BY
  PROVIDERS AND GUARD AGAINST COMPLACENCY
• NETWORK WITH OTHER COMMUNITY HEALTH CENTERS IN
  UNDERSERVED AREAS TO HELP CLOSE THE QUALITY CHASM